Tests treatments & procedures health professionals should question

The Royal Australian and New Zealand College of Radiologists – Faculty of Radiation Oncology

RANZCR is a non-profit association that delivers skills, knowledge, and insight to promote the science and practice of the medical specialties of clinical radiology (diagnostic and interventional) and radiation oncology.

Whole-breast radiation therapy decreases local recurrence and improves survival of women with invasive breast cancer treated with breast conservation therapy. Most studies have utilised “conventionally fractionated” schedules that deliver therapy over 5-6 weeks, often followed by 1-2 weeks of boost therapy. Recent studies, however, have demonstrated equivalent tumour control and cosmetic outcome in specific patient populations with shorter courses of therapy (∼4 weeks). Patients and their physicians should review these options to determine the most appropriate course of therapy.Recommendation released October 2016

Supporting Evidence

Clarke M, Collins R, Darby S, et al. Effects of radiotherapy and of differences in the extent of surgery for early breast cancer on local recurrence and 15-year survival: an overview of the randomised trials. Lancet 2005; 366:2087-106.

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Patients with prostate cancer have a number of reasonable management options. These include surgery and radiation, as well as conservative monitoring without therapy in appropriate patients. Shared decision making between the patient and the physician can lead to better alignment of patient goals with treatment and more efficient care delivery. ASTRO has published patient-directed written decision aids concerning prostate cancer and numerous other types of cancer. These types of instruments can give patients confidence about their choices, improving compliance with therapy.Recommendation released October 2016

Weerakoon M, Papa N, Lawrentschuk N, et al. The current use of active surveillance in an Australian cohort of men: a pattern of care analysis from the Victorian Prostate Cancer Registry. BJU Int 2015 Apr;115,Suppl 5:50-6.

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Studies suggest equivalent pain relief following 30 Gy in 10 fractions, 20 Gy in 5 fractions, or a single 8 Gy fraction. A single treatment is more convenient but may be associated with a slightly higher rate of retreatment to the same site. Strong consideration should be given to a single 8 Gy fraction for patients with a limited prognosis or with transportation difficulties.Recommendation released October 2016

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Randomised studies have demonstrated no overall survival benefit from the addition of adjuvant whole brain radiation therapy (WBRT) to stereotactic radiosurgery (SRS) in the management of selected patients with good performance status and brain metastases from solid tumours. The addition of WBRT to SRS is associated with diminished cognitive function and worse patient-reported fatigue and quality of life. These results are consistent with the worsened self-reported cognitive function and diminished verbal skills observed in randomised studies of prophylactic cranial irradiation for small cell or non-small cell lung cancer. Patients treated with radiosurgery for brain metastases are at higher risk of developing metastases elsewhere in the brain. Careful surveillance and the judicious use of salvage therapy at the time of brain relapse allow appropriate patients to enjoy the highest quality of life without a detriment in overall survival. Radiation oncologists should discuss these options with patients, including participation in appropriate clinical trials.Recommendation released October 2016

Supporting Evidence

Soffietti R, Kocher M, Abacioqlu UM, et al. A European organisation for research and treatment of cancer phase III trial of adjuvant whole-brain radiotherapy versus observation in patients with one to three brain metastases from solid tumours after surgical resection or radiosurgery: quality-of-life results. J Clin Oncol 2013;31(1):65-72.

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5. Don’t routinely use extensive locoregional therapy in most cancer situations where there is metastatic disease and minimal symptoms attributable to the primary tumour.

In the past, extensive local regional therapies (e.g., surgery) were often provided in patients with metastatic disease, regardless of the symptomatology of the primary tumour. However, recent evidence has suggested that in many cases these therapies do not improve outcome and, at times, delay the more important treatment of metastatic disease (e.g., chemotherapy). In general, patients with metastatic disease from solid organ malignancies and a relatively asymptomatic primary tumour should be considered for systemic therapy as a priority; the delay in systemic therapy and potential additional morbidity arising from extensive locoregional therapies should be avoided in these patients.Recommendation released October 2016

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How was this list created?

Radiation oncology recommendations 1-5 (October 2016)

Recommendations relating to radiation oncology from the Choosing Wisely and Choosing Wisely Canada were circulated around the Faculty of Radiation Oncology Council to determine which recommendations were applicable to the Australian and New Zealand context. The selected recommendations were then put to the Quality Improvement Committee and the Economics and Workforce Committee, with each being asked to rank the recommendations.

The five highest ranked recommendations were then put to the radiation oncology membership for consultation prior to being formally approved by the Faculty of Radiation Oncology Council.

Recommendations 1-3 are adapted from the American Society for Radiation Oncology (ASTRO) 2013 and 2014 lists. Recommendation 4 is adapted from Choosing Wisely Canada’s Oncology list.Each organisation was approached for—and subsequently granted—approval to adapt these recommendations as part of the Choosing Wisely New Zealand initiative.